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Key Words: Decision making; Diagnosis; Physical therapy profession, professional issues.
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Physical Therapy . Volume 83 . Number
5 . May 2003
455
JM Rothstein, PT, PhD, FAPTA, is Professor, Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago,
1919 W Taylor St, 4th Fl, Room 456, Chicago, IL 60612 (jules-rothstein@attbi.com). Address all correspondence to Dr Rothstein.
JL Echternach, PT, EdD, ECS, FAPTA, is Professor and Eminent Scholar, School of Physical Therapy, Old Dominion University, Norfolk, Va.
DL Riddle, PT, PhD, is Professor, Department of Physical Therapy, Medical College of Virginia Campus, Virginia Commonwealth University,
Richmond, Va.
All authors provided concept/idea/project design, writing, and project management. The authors acknowledge the efforts of Andrew Guccione,
PT, PhD, FAPTA, Julie Fritz, PT, PhD, ATC, and David Scalzitti, PT, MS, OCS, for reviewing an earlier draft of the manuscript.
This article was submitted March 12, 2002, and was accepted December 2, 2002.
456 . Rothstein et al
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Rothstein et al . 457
and the algorithm provides parallel paths for the management of the 2 types of problems. This is particularly
important in the reassessment phase (Part 2 of the
algorithm). The existence of a list of anticipated problems and the predictive criteria allows for the identification of which interventions are designed for prevention,
how these interventions are justified, and when intervention can be stopped. A novel element of the HOAC II,
one that we believe has not previously been seen in
physical therapy literature, are mechanisms to make
interventions designed for prevention goal oriented and
of determinate duration (ie, there is a stated goal that
must be achieved and there is an expectation as to how
long this will take).
The algorithm provides clinicians with a mechanism for
planning and evaluating activities designed for prevention. This approach encourages therapists to work to
minimize risks through prevention, but, more importantly, it allows them to evaluate their efforts and to
describe and justify their efforts to one another, payers,
managers, and others. Because in HOAC II prevention
activities are goal driven and are planned for specified
periods of time, therapists can, through use of the
algorithm, identify to payers the resources they will need
to achieve prevention. This should, in our opinion,
assure payers that interventions will not continue indefinitely, unless that can be justified before the initiation
of the intervention. The algorithm also allows the therapists to document when, in their professional opinions,
prevention activities are needed and the consequences
of what will occur if these are not carried out (eg, due to
a lack of patient adherence or because they are not
authorized by payers).
In a continued effort to keep focus on what are truly the
patients goals, one problem list (the PIP list) is generated before the examination. In the HOAC II, there is a
record, at least initially, of who identified the problem. A
complete problem list, however, including problems
identified by the therapist and others, and a complete set
of goals are not generated until later in the process.
Figures 1 and 2 illustrate Part 1 of the HOAC II.
In Part 2 of the HOAC II, there are 2 reassessment paths,
one for existing problems and one for anticipated
problems (Figs. 3 and 4). In each case, there are
questions on a flow diagram that direct therapists
through relatively simple steps that are taken in response
to questions. Two flow diagrams are used to describe the
reassessment, one for existing problems and one for
anticipated problems. A list of commonly used terms
operationally defined for the HOAC II is provided in the
Appendix.
458 . Rothstein et al
Figure 1.
The initial steps of Part 1 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).
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Physical Therapy . Volume 83 . Number
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Rothstein et al . 459
Figure 2.
The final steps of Part 1 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).
460 . Rothstein et al
Figure 3.
The algorithm for reassessment of existing problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).
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Figure 4.
The algorithm for reassessment of anticipated problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).
462 . Rothstein et al
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464 . Rothstein et al
Many physical therapy interventions focus on impairments and functional limitations, and therefore most
diagnostic hypotheses will be directed at the impairment
and functional limitation dimensions. Sometimes, however, therapists will attempt to eliminate a pathology.
When this occurs, the pathology is the hypothesized
cause. When a therapist believes that a wound fails to
close because of infection, for example, the hypothesis
could be at the level of a pathology; that is, unless the
sepsis is eliminated, the wound will not close. This would
be a testable hypothesis because wound cultures could
be requested. Hypotheses that identify suspected pathologies often cannot be tested by physical therapists
because most therapists are unable to request invasive
tests or radiological diagnostic tests. Therapists usually
need to consult with and possibly refer patients to a
physician to determine when a pathology is identified as
the diagnosis in a hypothesis.10
The HOAC II, like the original algorithm, places an
emphasis on hypothesis generation and requires the
therapist not only to determine what may be causing the
problem (eg, loss of muscle force, loss of motion), but to
also postulate as to the magnitude of the deficits (eg, how
much weakness a patient has and how much force would
be needed for the problem to be eliminated). The
amount of force needed will serve as the testing criteria
for the hypothesis. Therefore, when generating hypotheses, therapists must understand that in a subsequent
step they must quantify what must be achieved to eliminate the problem. One way of determining whether a
hypothesis is appropriate is to consider whether such
testing criteria could be generated. In the wound example, the criteria would be a report of a negative culture.
This example demonstrates that even when the hypothesis is at the level of pathology, generation of testing
criteria must be possible.
Hypotheses that identify impairments as the cause of
disabilities and functional losses are even easier to
generate. If a person cannot walk following a CVA, for
example, it would be incorrect in the HOAC II to
hypothesize that the cause is damage to the motor
cortex. Although this may be true, the quantification of
the type and extent of pathology is not observable and
measurable by physical therapists. The diagnostic
hypothesis may be that the person cannot walk because
he or she lacks the ability to generate sufficient quadriceps femoris muscle force during stance. In this example, the problem is a functional deficit, and the hypothesis relates the functional deficit to an impairment. The
testing criteria will be the amount of force the therapist
believes the patient needs to be able to generate to
eliminate the problem (ie, to walk). Had the hypothesis
identified a pathology (damage to the motor cortex),
the pathology could not be measured by physical thera-
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466 . Rothstein et al
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468 . Rothstein et al
intervention. Family members, other health care personnel (eg, physical therapist assistants), and other caregivers all may have a role in implementing tactics. The
physical therapist, however, should note who is implementing which tactics. We believe the therapist must
recognize that, as long as these tactics are part of the
physical therapy plan of care, the therapist must assume
responsibility for overseeing, evaluating, and determining whether modifications should be made to tactics.
Part 2
In Part 1 of the HOAC II, the therapist working with the
patient and others developed an intervention plan (a
series of strategies and tactics that is conceptually similar
to the plan of care as defined in the Guide).6 Justification for the interventions was based on the therapists
concepts of what was causing problems. Therefore, by
definition, much of what occurs in Part 1 arises from
conceptual models that can only be examined in the
context of intervention (eg, did the intervention lead to
a desired outcome?). Part 2 is far less conceptual in
nature and consists of questions that are designed to
provide insights into whether any aspect of patient
management is deficient, including whether the original
goals were viable.
The steps in Part 2 can be used for documentation, or
they can be used to less formally guide decision making.
The most important element, however, is that, by using
Part 2, the therapist must account for all changes in
goals, tactics, strategies, and hypotheses. In addition, the
therapist needs to document whether the criterion measure chosen is still viable and whether it is still reasonable
to expect to see the desired change in the criterion
measure. Part 2 not only assists in the evaluation process,
it provides the logical framework for examining the
effects of all interventions. Use of Part 2 requires the
therapist to document what happened to a patient, even
if the result is an acknowledgment that the result was less
than was expected. Documentation may be particularly
useful on occasions when factors outside of the therapists control led to a termination of the intervention.
For example, by following the steps in Part 2, a therapist
can make an argument to a payer that goals were not
achieved (even though progression was being made on
the criterion measure) because there was too little time
allowed for the intervention.
Part 2 consists of 2 flow diagrams. The first diagram
(Fig. 3) leads the therapist through a series of questions
for all existing problems (regardless of who generated
them). The second diagram (Fig. 4) also consists of a
series of questions, but these questions relate to anticipated problems (regardless of who generated the problem list). The peculiar nature of prevention (ie, therapists may take credit for what does not occur by making
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Rothstein et al . 469
Appendix.
470 . Rothstein et al
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